Viagra and nitro hypotension

[fakingpatience]

Would you be concerned with too much fluid for this patient? I only ask because I had a similar patient during paramedic ride time (he felt dizzy and vomited, so he took 2 nitros, which bottomed out his pressure, 60 something systolic on my initial assessment). My preceptor wanted me to be cautious with fluid administration, because he said that once the effects of the nitro wears off, and the patient vasoconstricts, they could go into fluid overload if you gave them excessive amounts of fluid. I ended up 500cc, which along with low semi-folowers (was sitting up on toilet initially) brought his pressure up into the 90s, and resolved his dizziness. So obviously not as severe as the pt you are describing, but I still wonder if that would be a consideration.

[krumel]

I only had one case where we had a similar situation. 66y/o, lied to us when asked about previous medication... Ended up with massive hypotension, HR of 40 and apnoea at one stage.

Treatment basically was the same as yours: Fluid (1000ml Bolus, 500ml of that pressurized), initially some epi (0.1mg) as a bolus, then we switched over to noradrenaline via syringe driver (I'm aware that Dobutamin might have been the better choice..but our choice was quite limited. Epi/Nor/nothing ) with 14 µg/min.

In regards of the fluid overload: The position of the cardiac-center of my old work region goes into the direction that they are not "as afraid of the overload than the dehydrated" patient...

[twist27896]

In regards to earlier posts, his BP was around 50 systolic upon arrival and decreased to the 30's enroute to the hospital (I'm not sure how accurate the monitor is on BP but we didn't have time to try and get a manual pressure with everything going on). I'm an EMT-I and was working with a paramedic. I know that we probably were able to get around 1.25L NS via 2 16 gauges (pressurized via squeezing) but I am not sure about the epi dosage-- as an intermediate it is out of my scope to use it to treat this specific situation so the paramedic handled it. I was thinking that PASG pants might have helped, too bad they took them off our trucks...

[paramedicmike]

Just as an aside, when I was in paramedic school we did an experiment regarding IV flow rates. Several classmates insisted that fluids under pressure would flow in faster than a normal gravity line. We determined that a gravity flow wide open IV flowed faster than IV fluids under pressure (in our case with a pressure bag). I understand the temptation when infusing fluids to squeeze the bag thinking you'll get them in faster. But that isn't really the case. By letting the fluid run wide open you would have still gotten the fluid in while freeing up at least on set of hands for a manual BP.

Not trying to Monday morning quarterback. Just throwing that out to keep in mind for the future in light of you not being sure how accurate the monitor might have been. For an NIBP measurement that came up that low I'd definitely want a manual, circumstances permitting, to confirm the numbers.

Good discussion. Thanks for coming back with more info. When are you going to paramedic school?

[krumel]

Sorry, that is wrong. Plain wrong.

1. Regarding the hands free: For that a more advanced service has pressure infusors or infusion cuffs... (similar to the ones you use for an art line)

2. Regarding the benefit: Your "experiment" is only valid (if it is valid at all)if you test it against a zero resistance infusion target. Infusing inside a vascular system that has things like its own pressure, valves and a vascular-muscle tone is a hole different setting (not even considering things like Bernoulli/Venturi or the fact that the "smallest" point is not the giving set but the exit of the IV-Cath)...

BTW: The flowrate of a 14G free flowing IV is somewhere around 300ml... I personally worked with an pressure device that brings in 1500ml within a minute thru one 14G....

[DwayneEMTP]

I don't know the answer to the above two posts, but I love that it became part of the thread.

I do know that most of my patients need quite a bit of fluid and that I tend to run it through 16s/18s most times, and that drops in the drop chamber become a stream instead when I squeeze the bag, but of course I can't guarantee that that means increased flow. I've just always assumed that it did.

[chbare]

Both have valid points and physiological assumptions; however, what does the evidence say?

http://www.ncbi.nlm....pubmed/10149684

http://www.google.co...HS_FTBKaBOVpLeg

Krumel, why do you believe dobutamine would be the best choice? There are a very narrow list of indications for dobutamine related to it's rather specific effects that focus mainly on enhancing myocardial contractility. In this case, the patient is suffering from a loss of preload and enhancing contractility will be of little use. In fact, one of the dobutamine isomers may have vasodilating properties.

[DwayneEMTP]

Yeah, I wouldn't be terribly afraid of fluid overload depending on the age and overall medical condition of the patient.

I think that most medics give their "Be careful of fluid overload!" warnings based on what they were taught in school as opposed to what they've seen themselves or read in the literature.

I once had a 90ish year old woman, lifelong health nut, in amazingly good health, still jogged, etc. She was complaining of leg pain. She'd gotten out of bed, felt light headed, fallen, and pulled a groin muscle (in my opinion.). She had no other complaints at the time. She claimed no significant previous medical history or meds, and I believed her as well, her really healthy looking family that she lived with stated the same.

During the assessment it was found that she had been ill for a week or so and had spent much of that time in bed. She'd not been feeling like eating or drinking much. Skin turgor was poor, pulse elevated, (can't remember) b/p was 80ish/50ish, lung sounds diminished all fields. Her main complaint, after we'd moved away from the leg issue was a persistent dry cough for the last several days.

She agreed to transport, I started an IV, ran a 500cc bolus of NS and monitored for a few mins. It was about an hours transport. She seemed to feel better, lungs sounded like they were expanding better, so I ran another 500ccs. This was followed by another after another assessment, with perhaps 40 mins passing before the last bolus.

She reported feeling 'wonderful!', her lungs were expanding much better it seemed, she'd developed some really light, dispersed rhonki, which I'd expected after being rehydrated after several days of a dry cough, her pulse dropped down to the mid 70's, and her bp came up to the low 120s/systolic.

I was really proud of this treatment. I believed, and continue to believe that it was appropriate and that the patient was much better off than when I'd found her. The nurse in the ER went friggin balistic! "You never give an elderly patient more than 500ccs of fluid! Never!"

I said, "But she's doing really well, right?"

She said, "Yeah, but you don't have to be here for the CHF that you've caused!" (Really? I caused CHF with fluids?)

Having seen her reaction, I was confident that this was going to generate a complaint so I followed her through the day. I asked the ER doc what he thought, and he felt that it was appropriate treatment. I followed up with her doctor who later came to see her at the ER who stated, "Pretty aggressive, but not inappropriate, and she's had no negative effects from it." and then the next day (They'd held her overnight secondary to the muscle strain for some reason.) her family doctor claimed no issues.

So, was it good treatment? Yeah, I think so. It was also one of two calls that this company used to fire me, so there's that.

Would I recommend this treatment for all geriatrics? Of course not. But I feel that my assessment was solid, and it seem appropriate here.

Why am I writing, and making you read all of this bullshit? Two reasons. The first is that I'm sitting in the middle of the jungle while it rains buckets outside, so I have nothing to do but torment you.

The second is to try and make the point that we don't have nearly enough information to know whether or not we would be afraid of overloading your patient with fluid. Again, not sniping...A thorough assessment followed by continued assessment is the answer to your question I think.

Excellent thread. See what you've started? We're all learning things from it..

[krumel]

@chbare:You are totally right... I had a massiv logic bug when writing that.. My way of thinking was to use the quite selective contractility increase to "fight" the decreasing pressure in the vital organs. But.... After reading it again I can't believe I wrote that... I will blame the massive flu I currently have for that Thanks for the correction!

[Off Label]

Just as an aside, when I was in paramedic school we did an experiment regarding IV flow rates. Several classmates insisted that fluids under pressure would flow in faster than a normal gravity line. We determined that a gravity flow wide open IV flowed faster than IV fluids under pressure (in our case with a pressure bag). I understand the temptation when infusing fluids to squeeze the bag thinking you'll get them in faster. But that isn't really the case. By letting the fluid run wide open you would have still gotten the fluid in while freeing up at least on set of hands for a manual BP.

 

Not trying to Monday morning quarterback. Just throwing that out to keep in mind for the future in light of you not being sure how accurate the monitor might have been. For an NIBP measurement that came up that low I'd definitely want a manual, circumstances permitting, to confirm the numbers.

 

Good discussion. Thanks for coming back with more info. When are you going to paramedic school?

Read Poiseuille's law

In regards to earlier posts, his BP was around 50 systolic upon arrival and decreased to the 30's enroute to the hospital (I'm not sure how accurate the monitor is on BP but we didn't have time to try and get a manual pressure with everything going on). I'm an EMT-I and was working with a paramedic. I know that we probably were able to get around 1.25L NS via 2 16 gauges (pressurized via squeezing) but I am not sure about the epi dosage-- as an intermediate it is out of my scope to use it to treat this specific situation so the paramedic handled it. I was thinking that PASG pants might have helped, too bad they took them off our trucks...

I'd give vasopressin over epi if I could. Contractility isn't his problem, loss of vasomotor tone is.